Survey of Transitional Care Between Pediatrics and Obstetrics/Gynecology in Japan

Purpose: This study's aim was to determine the actual status of transitional care for patients with pediatric cancer (PPCs) in Japan by surveying obstetricians/gynecologists. Methods: A questionnaire survey on transitional medicine was conducted in the form of an online questionnaire at 579 major training facilities nationwide, which were registered with the Japanese Society of Obstetrics and Gynecology. Results: While 40% of the facilities had received referrals for PPCs, only 13% provided transitional care specifically for PPCs. The most common problems with referrals were related to "insufficient explanation." In addition, at facilities with no experience treating PPCs, many respondents commented that they did not know how to follow the progression of the disease. Regarding the necessity of obstetrics/gynecology visits for PPCs, more than half of the respondents at facilities with experience treating PPCs answered that such visits were "necessary"; only 1% answered that they were "unnecessary." On the other hand, 37% of the facilities that had no experience treating PPCs answered that it was "necessary," whereas 4% answered that it was "unnecessary." Conclusions: This survey of the actual status of transitional care between pediatrics and obstetrics/gynecology in Japan identified issues to be addressed for the spread of transitional care. The results suggest that, in the future, health care professionals need education to increase their knowledge, and that patient education that leads to patients' awareness of their own self-management is necessary.

Comparing approaches to identify live births using the Transformed Medicaid Statistical Information System

OBJECTIVE

To evaluate the performance of different approaches for identifying live births using Transformed Medicaid Statistical Information System Analytic Files (TAF).

DATA SOURCES

The primary data source for this study were TAF inpatient (IP), other services (OT), and demographic and eligibility files. These data contain administrative claims for Medicaid enrollees in all 50 states and the District of Columbia from January 1, 2018 to December 31, 2018.

STUDY DESIGN

We compared five approaches for identifying live birth counts obtained from the TAF IP and OT data with the Centers for Disease Control and Prevention (CDC) Natality data-the gold standard for birth counts at the state level.

DATA COLLECTION/EXTRACTION METHODS

The five approaches used varying combinations of diagnosis and procedure, revenue, and place of service codes to identify live births. Approaches 1 and 2 follow guidance developed by the Centers for Medicare and Medicaid Services (CMS). Approaches 3 and 4 build on the approaches developed by CMS by including all inpatient hospital claims in the OT file and excluding codes related to delivery services for infants, respectively. Approach 5 applied Approach 4 to only the IP file.

PRINCIPAL FINDINGS

Approach 4, which included all inpatient hospital claims in the OT file and excluded codes related to infants to identify deliveries, achieved the best match of birth counts relative to CDC birth record data, identifying 1,656,794 live births-a national overcount of 3.6%. Approaches 1 and 3 resulted in larger overcounts of births (20.5% and 4.5%), while Approaches 2 and 5 resulted in undercounts of births (-3.4% and -6.8%).

CONCLUSIONS

Including claims from both the IP and OT files, and excluding codes unrelated to the delivery episode and those specific to services rendered to infants improves accuracy of live birth identification in the TAF data.

"It just wasn't right down there": Surgical treatment of small bowel evisceration after hysterectomy with indocyanine green angiography, a case report

This is a case of a 70-year-old female with small bowel evisceration through vaginal cuff dehiscence 14 months after hysterectomy. She presented with a loop of ileum herniated through the vagina. The bowel was irreducible and she was taken to the operating room for exploratory laparotomy, reduction of herniated bowel contents, and repair of vaginal cuff. During surgery, the eviscerated bowel had questionable viability and indocyanine green angiography was used to assess perfusion. After the repair of the vaginal cuff, indocyanine green angiography was performed and the bowel was saved from resection. In the discussion, light is shed upon the rarity of vaginal cuff dehiscence and the few cases of small bowel evisceration after a dehiscence. Possible causes of the evisceration, updates to technique, and recommendations for management are also discussed. The ultimate recommendation is for use of indocyanine green angiography in assessment of intestinal viability during surgical exploration for small bowel evisceration.

"Veozah (Fezolinetant): A Promising Non-Hormonal Treatment for Vasomotor Symptoms in Menopause"

Vasomotor symptoms (VMS) are a common and distressing experience during menopause, affecting a significant portion of women. Hormone therapy (HT) has been the traditional treatment, but its limitations and potential risks have led to the search foar non-hormonal alternatives. Recently, the FDA approved Veozah (Fezolinetant) as a promising nonhormonal solution for moderate to severe VMS in menopause. Veozah, an innovative neurokinin 3 (NK3) receptor antagonist, targets the disrupted thermoregulation underlying VMS. It modulates neural activity within the thermoregulatory center by crossing the blood-brain barrier, offering relief from hot flashes and night sweats. Clinical trials, including SKYLIGHT 1TM, SKYLIGHT 2TM, and SKYLIGHT 4TM, have established Fezolinemtant's efficacy and safety profile. The recommended dosage of one 45 mg tablet per day demonstrates proportional pharmacokinetics, with generally mild side effects that require regular monitoring. Fezolinetant's oral availability makes it a convenient and accessible option for women seeking relief from VMS, potentially improving their overall well-being.

Surgical management of a type A aortic dissection in a pregnant patient

Despite emphasis for emergent surgical treatment of Stanford type A aortic dissections, pregnant patients that are clinically stable may safely receive a staged approach instead, with delivery followed by delayed dissection repair.

Perceptions of Obstetrics/Gynecology Surgeons on Non-medically Indicated Cesarean Sections: A Cross-Sectional Study

BACKGROUND

Numerous factors can influence decisions regarding the type of delivery of human babies. There is an increasing demand for non-medically indicated cesarean sections (CS) (non-miCS) or CS on request (CSor). Therefore, this survey study aimed to identify the factors that may foster the decision of CS among obstetricians.

METHODS

After the sample size calculation returned with 132 needed participants, confidence surveys were sent electronically or disseminated in paper form to nearly all obstetricians (around 200) in the province between mid-August 2021 and mid-February 2022. After signing the consent form, obstetricians were able to provide responses to the four sections of the questionnaire. Data from the copies of the paper were entered into Excel by a local data collector. The data analysis was done using Statistical Product and Service Solutions (SPSS) (IBM SPSS Statistics for Windows, Armonk, NY) and followed the following sequence: summary statistics were done first; then the groups (for and against non-miCS) were compared using analysis of variance (ANOVA); and, finally, regression models were conducted to determine the factors that may affect the favorability of doing non-miCS.

RESULTS

A total of 104 obstetricians responded to the survey. Approximately 62.5% of them performed CSor for women who requested it. In addition, more than half (57.7%) agreed that all women had the right and autonomy to choose their mode of delivery. Most providers (65.4) agreed that fear of vaginal delivery (VD) and a bad experience with it are rational reasons for performing a CSor. Unfortunately, some obstetricians (18.3%) faced lawsuits when they refused to perform CSor. As for the factors that may influence the acceptance of obstetricians to non-miCS, it was found that obstetricians who are unsure or refuse to answer (OR=4.30, 95%-CI 1.25-16.29, p=0.025), along with people who do not always perform CSor (OR=4.33, 95%-CI 1.59-12.50, p=0.005) or even refuse it (3.54, 95%-CI 1.05-12.96, p=0.046), are more likely to agree that women have the right to request CSor.

CONCLUSION

The surge in CSor rates was mostly correlated with an attempt to escape the fear of VD. However, given the wide discrepancies in obstetricians' opinions in this survey, we cannot draw firm conclusions about the reasons behind this phenomenon. It is also important to explore possible ways to address the problem, such as through litigation with providers who refuse to perform a CSor and through economic reform to protect women from money-grubbing obstetricians.

Changes in prenatal care and birth outcomes after federally qualified health center expansion

OBJECTIVE

To evaluate whether the expansion of Federally Qualified Health Centers (FQHCs) improved late prenatal care initiation, low birth weight, and preterm birth among Medicaid-covered or uninsured individuals.

DATA SOURCES AND STUDY SETTING

We identified all FQHCs in California using the Health Resources and Services Administration's Uniform Data System from 2000 to 2019. We used data from the U.S. Census American Community Survey to describe area characteristics. We measured outcomes in California birth certificate data from 2007 to 2019.

STUDY DESIGN

We compared areas that received their first FQHC between 2011 and 2016 to areas that received it later or that had never had an FQHC. Specifically, we used a synthetic control with a staggered adoption approach to calculate non-parametric estimates of the average treatment effects on the treated areas. The key outcome variables were the rate of Medicaid or uninsured births with late prenatal care initiation (>3 months' gestation), with low birth weight (<2500 grams), or with preterm birth (<37 weeks' gestation).

DATA COLLECTION/EXTRACTION METHODS

The analysis was limited to births covered by Medicaid or that were uninsured, as indicated on the birth certificate.

PRINCIPAL FINDINGS

The 55 areas in California that received their first FQHC in 2011-2016 were more populous; their residents were more likely to be covered by Medicaid, to be low-income, or to be Hispanic than residents of the 48 areas that did not have an FQHC by the end of the study period. We found no statistically significant impact of the first FQHC on rates of late prenatal care initiation (ATT: -10.4 [95% CI -38.1, 15.0]), low birth weight (ATT: 0.2 [95% CI -7.1, 5.4]), or preterm birth (ATT: -7.0 [95% CI -15.5, 2.3]).

CONCLUSIONS

Our results from California suggest that access to primary and prenatal care may not be enough to improve these outcomes. Future work should evaluate the impact of ongoing initiatives to increase access to maternal health care at FQHCs through targeted workforce investments.

Implementation of an Epidural Rounding Reminder in the Electronic Medical Record Improves Performance of Standardized Patient Assessments during Labor

BACKGROUND

Poorly functioning labor epidural catheters lead to pain and dissatisfaction. Regular catheter assessment ensures timely identification of malfunction and may improve safety by facilitating rapid and successful conversion to general anesthesia for emergency cesarean. Informatics-based systems encourage standardization of care to identify epidural malfunctions earlier.

OBJECTIVES

This article demonstrates that visual epidural rounding reminder display on an electronic patient board would alert clinicians to elapsed time and decrease mean time between assessments.

METHODS

As a quality initiative, we implemented an epidural rounding reminder on our obstetric patient board. The reminder indicated the number of elapsed minutes since placement or last patient assessment. We retrospectively reviewed labor epidural charts 3 months prior to and 5 months following reminder implementation, with a 4-week washout period. The primary outcome was mean time between documented epidural assessments, with secondary outcomes including maximum time between assessments, total number of assessments during labor, catheter replacement rates, and patient satisfaction. Unadjusted comparisons between pre- and postimplementation groups were conducted using Wilcoxon's rank-sum and Pearson's chi-square tests, as appropriate. A test for equal variances was conducted for time between assessment outcomes.

RESULTS

Following implementation, mean time between assessments decreased from a median of 173 (interquartile range [IQR]: 53, 314) to 100 (IQR: 74, 125) minutes (p <0.001), and maximum time between assessments decreased from median 330 (IQR: 60, 542) to 162 (IQR: 125, 212) minutes (p < 0.001). Total number of evaluations during labor increased from 3 (IQR: 2, 4) to 5 (IQR: 3, 7; p < 0.001). Decreased variance in mean and maximum time between assessments was noted following reminder implementation (p < 0.001). Epidural replacement rates decreased from 14 to 5% postimplementation (p < 0.001). Patient satisfaction was unchanged.

CONCLUSION

Implementation of an informatics-based solution can promote standardization of care. A simple epidural rounding reminder prompted clinicians to perform more frequent labor epidural assessments. In the future, these process improvements must be linked to improvements in patient experiences and outcomes.

Group Prenatal Care and Emergency Room Utilization

Pregnancy-related complaints are a significant driver of emergency room (ER) utilization among women. Because of additional time for patient education and provider relationships, group prenatal care may reduce ER visits among pregnant women by helping them identify appropriate care settings, improving understanding of common pregnancy discomforts, and reducing risky health behaviors. We conducted a retrospective cohort study, utilizing Medicaid claims and birth certificate data from a statewide expansion of group care, to compare ER utilization between pregnant women participating in group prenatal care and individual prenatal care. Using propensity score matching methods, we found that group care was associated with a significant reduction in the likelihood of having any ER utilization (-5.9% among women receiving any group care and -6.0% among women attending at least five group care sessions). These findings suggest that group care may reduce ER utilization among pregnant women and encourage appropriate health care utilization during pregnancy.

Patterns of black and white hysterectomy incidence among reproductive aged women

OBJECTIVE

To investigate the intersection of race and economic context in treatment with hysterectomy among reproductive aged women with noncancerous gynecologic conditions.

DATA SOURCES

We combined administrative billing records of inpatient and outpatient hysterectomy procedures (N = 28 301) occurring in North Carolina between 2011 and 2014 with census data to calculate county-level hysterectomy rates.

STUDY DESIGN

Spatial analysis techniques examined the distribution of black and white hysterectomy rates across counties, and county-level black and white rate differences were compared across economic contexts.

DATA COLLECTION/EXTRACTION

We restricted to those of premenopausal age identifying as non-Hispanic black or white, undergoing hysterectomy for nonemergent causes (N = 28 301 procedures).

PRINCIPAL FINDINGS

County-level hysterectomy rates were spatially patterned (Moran's I, P < .05) and similarly so for black and white women (LISA, P < .005). The black-white difference in hysterectomy rates was the largest in the high economic tier counties (22/10 000 person-years [PY], P < .05) and smallest in the mid and low economic tier counties (11/10 000 PY, P > .05 and 10/10 000 PY, P > .05, respectively).

CONCLUSION

Socioeconomic context is important to understand, particularly for black-white disparities in hysterectomy. Efforts should be made to understand the causes of higher rates of hysterectomy among blacks than whites, especially in counties in the highest economic tier.

A National Survey of Obstetrician/Gynecologists' Knowledge, Attitudes, and Beliefs Regarding Adult Human Papillomavirus Vaccination

Background: Many women see an obstetrician/gynecologist (OB/GYN) annually and receive their primary care from an OB/GYN. Understanding OB/GYNs' human papillomavirus (HPV) vaccination practices, including knowledge of and barriers to vaccination, is essential to design effective interventions to increase vaccination. This study evaluated OB/GYN knowledge, attitudes, and beliefs regarding vaccinating both younger (18-26 years) and mid-adult (27-45 years) women. Materials and Methods: Data were collected from OB/GYN providers in October 2019 through a nationwide web-based survey. Items included the following: HPV-related vaccination practices, recommendation strength, knowledge (seven items), benefits (four items), and barriers (eight items). Results: The sample (n = 224) was majority were White (69%), men (56%), and practice in suburban clinics (55%). Most (84%) reported they usually or always recommend HPV vaccine to eligible patients, but estimated only about half (51%) of other OB/GYNs did the same. Recommendation strength varied by patient age with 84% strongly recommending it to patients ≤18 years, compared with 79% and 25% strongly recommending to younger and mid-adult patients, respectively (p < 0.01). Participants reported lower benefits (p = 0.007) and higher barriers (p < 0.001) for 27- to 45-year-old patients compared with younger patients. Cost was the most frequently reported barrier, regardless of patient age. Overall knowledge was high (m = 5.2/7) but 33% of participants did not know the vaccine was safe while breastfeeding. Conclusions: Although providers reported strongly and consistently recommending the HPV vaccination to their adult patients, there were gaps in knowledge and attitudinal barriers that need to be addressed. Provider performance feedback may be important in improving HPV vaccination awareness among providers.

Mortality and glycemic control among patients with diabetes mellitus and uterine or ovarian cancer

Aim:

To evaluate associations between survival and glycemic control in age-matched patients with endometrial or ovarian cancer, with/without diabetes mellitus (DM).

Patients & methods:

Patients with newly diagnosed ovarian or endometrial cancer with and without DM were compared.

Results:

The study included 84 patients with ovarian cancer (28, DM); 96 with endometrial cancer (48 with, 48 without DM). DM patients did not have worse overall or progression-free survival than non-DM patients. Glycemic control was not associated with either cancer.

Conclusion:

There was no association between DM and survival for patients with uterine or ovarian cancer. In addition, there was no association between uterine and ovarian cancer and glycemic control. Additional studies to confirm these observations in larger populations are required.

The aim of this study was to evaluate the effect of diabetes mellitus (DM) on survival of patients with ovarian or uterine cancer and to determine whether ovarian and uterine cancer affected glycemic control. From an institutional cancer registry, patients with ovarian or uterine cancer were identified and grouped by DM or no DM. Groups were matched by age at cancer diagnosis. DM did not decrease survival and ovarian and uterine cancer did not significantly affect glycemic control in patients with DM.

Third-Generation Cephalosporin-Loaded Chitosan Used to Limit Microorganisms Resistance

From their discovery, antibiotics have significantly improved clinical treatments of infections, thus leading to diminishing morbidity and mortality in critical care patients, as well as surgical, transplant and other types of medical procedures. In contemporary medicine, a significant debate regarding the development of multi-drug resistance involves all types of pathogens, especially in acute care hospitals due to suboptimal or inappropriate therapy. The possibility of nanotechnology using nanoparticles as matrices to encapsulate a lot of active molecules should increase drug efficacy, limit adverse effects and be an alternative helping to combat antibiotic resistance. The major aim of this study was to obtain and to analyze physico-chemical features of chitosan used as a drug-delivery system in order to stop the antibiotic resistance of different pathogens. It is well known that World Health Organization stated that multidrug resistance is one of the most important health threats worldwide. In last few years, nano-medicine emerged as an improved therapy to combat antibiotic-resistant infections agents. This work relies on enhancement of the antimicrobial efficiency of ceftriaxone against gram(+) and gram(-) bacteria by antibiotic encapsulation into chitosan nanoparticles. Physicochemical features of ceftriaxone-loaded polymer nanoparticles were investigated by particle size distribution and zeta potential, Fourier-transform infrared spectroscopy (FTIR), Thermal Gravimetric Analysis (TG/TGA), Scanning Electron Microscopy (SEM) characteristics techniques. The obtained results revealed an average particle size of 250 nm and a zeta potential value of 38.5 mV. The release profile indicates an incipient drug deliverance of almost 15%, after 2 h of approximately 83%, followed by a slowed drug release up to 24 h. Characteristics peaks of chitosan were confirmed by FTIR spectra indicating a similar structure in the case of ceftriaxone-loaded chitosan nanoparticles. A good encapsulation of the antibiotic into chitosan nanoparticles was also provided by thermo-gravimetric analysis. Morphological characteristics shown by SEM micrographs exhibit spherical nanoparticles of 30-250 nm in size with agglomerated architectures. Chitosan, a natural polymer which is used to load different drugs, provides sustained and prolonged release of antibiotics at a specific target by possessing antimicrobial activity against gram(+) and gram(-) bacteria. In this research, ceftriaxone-loaded chitosan nanoparticles were investigated as a carrier in antibiotic delivery.

Adverse Events in Obstetrics: Impacts on Providers and Staff of Maternity Care

Objective

To determine the frequency of maternity health employee experiences with maternal and perinatal/neonatal adverse outcomes and gain a deeper understanding of how these experiences impact the providers. 

Design

Single-institution observational study from 2016.

Setting

The George Washington University Hospital.

Population

Labor and delivery, postpartum, and neonatal intensive care staff.

Methods

An anonymous survey was distributed to maternity staff inquiring about feelings surrounding maternal and perinatal/neonatal adverse outcomes. Predictors included demographics and job-related variables. Associations were examined using univariable and multivariable analyses.

Main Outcome Measures

Outcomes included depression, post-traumatic stress disorder symptoms, and work-related problems following the event.

Results

 A total of 105 employees of approximately 230 eligible employees answered the survey, including obstetrics and gynecology and anesthesia physicians (residents and attendings), midwives, nurses, nurse practitioners, and medical technicians with a response rate of 46%. Being a physician was protective against symptoms of depression and post-traumatic stress disorder symptoms. Resident physicians had higher levels of anxiety/depression compared to attendings. Statistically significant variables predictive of negative repercussions included non-physician status (p=.045), substance use (p=.0036), considering a career change (p<.0001) and seeking mental health treatment (p=.0005). About half of the respondents were aware that processes exist to help them cope with adverse outcomes.

Conclusions

Non-physicians, those using substances, those considering career change, and those seeking mental health treatment are more likely to experience anxiety/depression and post-traumatic stress symptoms after a maternal or perinatal/neonatal loss. These individuals should be identified and offered additional support.

Choosing a hospital for obstetric, gynecologic, or reproductive healthcare: what matters most to patients?

BACKGROUND

Despite millions of U.S. women receiving obstetric/gynecologic or reproductive care in a hospital each year, little is known about which factors matter most to women in choosing a hospital for this care.

OBJECTIVE(S)

To describe women's reasons for choosing their hospital for obstetric/gynecologic or reproductive care, and to examine characteristics associated with reporting specific factors as important in hospital choice.

MATERIALS AND METHODS

We conducted a nationally representative, cross-sectional survey of women aged 18-45 years. The 2016 survey recruited women from AmeriSpeak, a probability-based research panel. A total of 1430 women completed the survey. All data analysis used weighting and accounted for the complex survey design. We conducted bivariate and multinomial logistic regression modeling to assess associations.

RESULTS

Three-fourths of women cited a hospital's overall reputation/quality as a reason, and one-third named this as the most important reason for choosing a hospital. A total of 14% reported hospital religious affiliation as a reason. Compared to those with no prior deliveries, women who had delivered an infant were more likely to report that their top reason was specialty services/provider (relative risk ratio, 2.97; 95% confidence interval, 1.96-4.52) and were also more likely to report overall hospital quality/reputation as their top reason (relative risk ratio, 1.52; 95% confidence interval, 1.06-2.17), compared to logistical reasons. Metropolitan versus non-metropolitan residence was also a significant factor in hospital choice.

CONCLUSION

Women endorse many factors when choosing a hospital for reproductive care, but perceived quality and reputation outweigh logistical concerns such as location and insurance.

Ischemic stroke and floating thrombosis in dissection of the common carotid artery in patient at third week of pregnancy: Surgical technical success and maintenance of pregnancy

Thrombosis, especially in pregnancy, is due to a prothrombotic state and involves the venous system. Localization in an arterial segment is rare. Floating carotid arterial thrombosis is a very rare occurrence, but it is very devastating. The authors report the case of a pregnant patient in whom are associated a thrombotic predisposition and a traumatic event of the neck which resulted in a limited dissection and a floating thrombosis of the common carotid artery. The onset was characterized by sudden neurological deficits, including numbness of the right-hand fingers and right limb weakness, which regressed after admission. The patient underwent a surgical operation with success. Her pregnancy continued, and an ultrasound scan 12 months later confirmed the patency of the prosthesis, in the absence of neurological symptoms. Hormonal changes may reveal the condition of thrombophilia, which, however, occurs more frequently in the venous system and is a condition related to the free-floating thrombus. No guidelines exist for medical or surgical management. The endovascular approach appears to present a greater risk of embolization as an alternative to open surgery. This case demonstrates that the prothrombotic state and the presence of neurological symptoms are suggestive of arterial thrombosis in pregnancy and that the multidisciplinary approach is mandatory to achieve good results.

HIV-Uninfected Kenyan Adolescent and Young Women Share Perspectives on Using Pre-Exposure Prophylaxis During Pregnancy

To optimize scale-up of pre-exposure prophylaxis (PrEP) for pregnant women at risk of HIV in high HIV burden settings, implementation strategies must be developed that account for perceptions of PrEP in this unique population. Semistructured focus group discussions were conducted with 68 HIV-uninfected Kenyan pregnant and postpartum women without prior PrEP knowledge or experience. A qualitative descriptive analysis was performed, using a constant comparison approach, to identify key themes related to the values and rationale impacting potential PrEP use in pregnancy. Median age was 19.5 years and participants were either pregnant or had 1-2 children. Almost all (96%) were married or had a steady partner. Women felt pregnancy was a time of high HIV risk because they desired sex less frequently, which may lead their partners to have outside partnerships. This made PrEP an attractive HIV prevention option for themselves and their infants. Although women believed male partner behaviors influenced their HIV risk, many women perceived that male partners would react negatively, including becoming physically violent, if they discovered that women used PrEP. Clinicians were identified as potential facilitators of PrEP use who could explain PrEP to male partners on behalf of pregnant women. Women said that community-level stigma against HIV and potential for conflating PrEP with antiretroviral therapy (ART) would necessitate that PrEP use be discreet. Our results indicate the importance of addressing risk perception of women, concerns of male partners, HIV stigma, and benefits of PrEP for HIV prevention as programs are developed for pregnant women.

Synchronous endometrial adenocarcinoma and carcinosarcoma in endometrial polyp

Introduction:

Carcinosarcoma is a rare gynecological malignancy and it usually follows an aggressive clinical course. Rarely, it can be confined to an endometrial polyp or be synchronous with another gynecological malignancy. Herein, we report a rare case of synchronous carcinosarcoma confined to an endometrial polyp and endometrioid endometrial adenocarcinoma arising from a distinct uterine wall site.

Case presentation:

A 57-year-old female patient presented with heavy vaginal bleeding. She underwent hysterectomy with bilateral salpingo-oophorectomy for endometrioid endometrial adenocarcinoma that was diagnosed preoperatively through dilation and curettage. Full histopathological examination of the uterine specimen revealed carcinosarcoma confined to a 4 cm endometrial polyp in addition to a stage IA endometrioid endometrial adenocarcinoma which arose from a distinct uterine wall.

Conclusion:

Having an endometrioid endometrial cancer diagnosis preoperatively through dilation and curettage and at examination of the frozen section specimen following surgical resection should not preclude the standard full histopathological examination of the uterine specimen, since this could reveal an additional uterine malignancy, such as carcinosarcoma. Such a finding would alter the post-operative management, prognosis, and outcome even if it is confined to an endometrial polyp.

Shifting Patterns in Cesarean Delivery Scheduling and Timing in Oregon before and after a Statewide Hard Stop Policy

OBJECTIVES

To assess the use and timing of scheduled cesareans and other categories of cesarean delivery and the prevalence of neonatal morbidity among cesareans in Oregon before and after the implementation of Oregon's statewide policy limiting elective early deliveries.

DATA SOURCES

Oregon vital statistics records, 2008-2013.

STUDY DESIGN

Retrospective cohort study, with multivariable logistic regression, regression controlling for time trends, and interrupted time series analyses, to compare the odds of different categories of cesarean delivery and the odds of neonatal morbidity pre- and postpolicy.

DATA COLLECTION/EXTRACTION METHODS

We analyzed vital statistics data on all term births in Oregon (2008-2013), excluding births in 2011.

PRINCIPAL FINDINGS

The odds of early-term scheduled cesareans decreased postpolicy (adjusted odds ratio [aOR], 0.70; 95 percent confidence interval [CI], 0.66-0.74). In the postpolicy period, there were mixed findings regarding assisted neonatal ventilation and neonatal intensive care unit admission, with regression models indicating higher postpolicy odds in some categories, but lower postpolicy odds after controlling for time trends.

CONCLUSIONS

Oregon's hard stop policy limiting elective early-term cesarean delivery was associated with lower odds of cesarean delivery in the category of women who were targeted by the policy; more research is needed on impact of such policies on neonatal outcomes.

Ultraminiature optical design for multispectral fluorescence imaging endoscopes

A miniature wide-field multispectral endoscopic imaging system was developed enabling reflectance and fluorescence imaging over a broad wavelength range. At 0.8-mm diameter, the endoscope can be utilized for natural orifice imaging in small lumens such as the fallopian tubes. Five lasers from 250 to 642 nm are coupled into a 125 - ? m diameter multimode fiber and transmitted to the endoscope distal tip for illumination. Ultraviolet and blue wavelengths excite endogenous fluorophores, which can provide differential fluorescence emission images for health and disease. Visible wavelengths provide reflectance images that can be combined for pseudo-white-light imaging and navigation. Imaging is performed by a 300 - ? m diameter three-element lens system connected to a 3000-element fiber. The lens system was designed for a 70-deg full field of view, working distance from 3 mm to infinity, and 40% contrast at the Nyquist cutoff of the fiber bundle. Measured performance characteristics are near design goals. The endoscope was utilized to obtain example monochromatic, pseudo-white-light, and composite fluorescence images of phantoms and porcine reproductive tract. This work shows the feasibility of packaging a highly capable multispectral fluorescence imaging system into a miniature endoscopic system that may have applications in early detection of cancer.

Predictors of Pregnancy in Female Veterans Receiving a Hormonal Contraceptive Pill, Patch, or Ring

BACKGROUND

Pregnancy rates in veterans are an understudied phenomenon.

OBJECTIVE

The objective of this study was to identify predictors of pregnancy within 1 year of starting hormonal contraception among female veterans.

METHODS

This was a retrospective, cohort study of female veterans from Veterans Affairs facilities within Southern California and Nevada, who newly started hormonal contraception (pill, patch, or ring only) between October 2008 and September 2012. Pregnancy was defined as any event corresponding to a pregnant state using ICD-9 codes. Patients were followed for 1 year post-initiation. Multivariate logistic regression analysis was performed.

RESULTS

The final analysis included a total of 2166 patients. Approximately 5.9% (n = 127) of patients became pregnant during follow-up. Increased odds of pregnancy were associated with the following: mental health disease (odds ratio [OR] 1.69, 95% confidence interval [CI] 1.15-2.58), lowest socioeconomic quintile (OR 1.50, 95% CI 1.05-2.09), and Christian faith (OR 1.69, 95% CI 1.31-2.41). Age groups 25 to 34 years (OR 0.55, 95% CI 0.38-0.92] and 35 to 44 years (OR 0.32, 95% CI 0.06-0.64) were both associated with decreased odds of pregnancy versus age group 18 to 24 years.

CONCLUSION

This study successfully identified several predictors of pregnancy in female veterans starting a pill, patch, or ring form of hormonal contraception. Female veterans in the lowest socioeconomic quintile, aged 18 to 24 years, diagnosed with a mental health disorder, and of Christian faith were found to be at significantly higher odds of a pregnancy. Identification of these at-risk populations may help clinicians and policy makers choose strategies to identify which patients could benefit the most from more effective long-acting reversible contraception therapy.

Views of preimplantation genetic diagnosis among psychiatrists and neurologists

OBJECTIVE

To examine key aspects of neurologists' and psychiatrists' views and approaches regarding prenatal genetic testing (GT) and preimplantation genetic diagnosis (PGD).

STUDY DESIGN

We surveyed attitudes and practices among 163 neurologists and 372 psychiatrists.

RESULTS

A total of 24.9% of neurologists and 31.9% of psychiatrists had discussed prenatal GT with patients, but 95.3% did not feel comfortable discussing PGD; only 2.9% discussed it, and only 1.8% had patients ask about PGD. Most would refer for PGD for Huntington's disease and Tay-Sachs disease, fewer for cystic fibrosis, and fewer still for autism, Alzheimer's disease, or gender selection for family balancing; in each of these cases, psychiatrists' percentages were higher than those of neurologists. Providers who would refer for PGD for Huntington's disease, cystic fibrosis, or gender selection differed from others in proportions of patients with insurance and were more likely to have undergone a GT themselves and be concerned about discrimination.

CONCLUSION

These data, the first to examine how neurologists and psychiatrists view PGD, suggest that they do not feel comfortable discussing PGD but have strong views about its use. Potential PGD use is associated with concerns about discrimination and less experience with GT. These data highlight the need for enhancing education about these technologies among various providers.

Regionalization and local hospital closure in Norwegian maternity care--the effect on neonatal and infant mortality

OBJECTIVE

To study whether neonatal and infant mortality, after adjustments for differences in case mix, were independent of the type of hospital in which the delivery was carried out.

DATA

The Medical Birth Registry of Norway provided detailed medical information for all births in Norway.

STUDY DESIGN

Hospitals were classified into two groups: local hospitals/maternity clinics versus central/regional hospitals. Outcomes were neonatal and infant mortality. The data were analyzed using propensity score weighting to make adjustments for differences in case mix between the two groups of hospitals. This analysis was supplemented with analyses of 13 local hospitals that were closed. Using a difference-in-difference approach, the effects that these closures had on neonatal and infant mortality were estimated.

PRINCIPAL FINDING

Neonatal and infant mortality were not affected by the type of hospital where the delivery took place.

CONCLUSION

A regionalized maternity service does not lead to increased neonatal and infant mortality. This is mainly because high-risk deliveries were identified well in advance of the birth, and referred to a larger hospital with sufficient perinatal resources to deal with these deliveries.

The impact of nurse case management home visitation on birth outcomes in African-American women

The views expressed in this article are those of the authors and do not necessarily reflect the official policy or position of the Uniformed Services University of the Health Sciences, Department of the Navy, Department of Defense or the U. S. government. Dr. Wells is a military service member (employee of the U.S. government). This work was prepared as a part of her official duties. Title 17, USC Section 101 defines a U.S. government work as a work prepared by a military service member or employee of the U.S. government as part of the person's official duties. Despite substantial reductions in U.S. infant mortality rates, racial disparities persist, with black Americans experiencing 2.4 times the rate of their white counterparts. Low birthweight and preterm delivery contribute to this disparity.

METHODS

To examine the association between antepartum nurse case management home visitation and the occurrence of low birthweight and preterm deliveries in African-American women in Montgomery County, MD, a retrospective cohort study was conducted using existing data from 109 mothers who were enrolled in the Black Babies Start More Infants Living Equally Healthy (SMILE) program. Logistic regression analysis was used.

RESULTS

Women who received antepartum home visits were 0.37 (CI 0.15-0.94) times less likely to experience preterm delivery than women who did not receive antepartum home visits. The effect of antepartum home visits on preterm delivery was independent of level of prenatal care, negative life events and number of prior live births. There was no significant association between antepartum home visits and low birthweight.

CONCLUSION

Antepartum home visits appeared to be protective against preterm delivery and could contribute to reducing racial disparities in infant mortality. Further study is needed to understand and replicate specific program components that may contribute to improved birth outcomes in African-American women.